Mondi Annalisa, Cozzi-Lepri Alessandro, Tavelli Alessandro, Cingolani Antonella, Giacomelli Andrea, Orofino Giancarlo, De Girolamo Gabriella, Pinnetti Carmela, Gori Andrea, Saracino Annalisa, Bandera Alessandra, Marchetti Giulia, Girardi Enrico, Mussini Cristina, d'Arminio Monforte Antonella, Antinori Andrea
Clinical Department of Infectious Diseases, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy.
Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, University College London, London, UK.
Int J Infect Dis. 2024 May;142:106995. doi: 10.1016/j.ijid.2024.106995. Epub 2024 Mar 6.
Limited data are available on the long-term outcomes in recent years for late HIV diagnosis (LD).
All subjects with HIV enrolled in the ICONA cohort in 2009-2022 who started antiretroviral treatment (ART) within 4 months from diagnosis were included and divided into: (i) pre-ART CD4 count ≥350/mm without AIDS (non-LD), (ii) pre-ART CD4 count <350/mm without AIDS (LD asymptomatic), and (iii) with AIDS events pre-ART (LD-AIDS). The estimated probability and independent risk for mortality (all-cause and cause-specific) and treatment failure were evaluated.
Of 6813 participants (2448 non-LD, 3198 LD asymptomatic, and 1167 LD-AIDS), 161 (2.4%) died after ART initiation. At survival analysis, a higher probability of all-cause mortality has been identified for LD than non-LD (P <0.001) and within the former, for LD-AIDS over LD asymptomatic (P <0.001). After adjusting for confounders, LD showed a higher risk of all-cause mortality (vs non-LD adjusted hazard ratio (aHR) 5.51, P <0.001) and, in particular, being an AIDS presenter predicted a greater risk of all-cause (aHR = 4.42, P <0.001), AIDS-related (adjusted subhazard ratio [aSHR] = 16.86, P <0.001), and non-AIDS-related mortality (aSHR = 1.74, P = 0.022) than the rest of the late presenters. Among the short-term survivors in the LD-AIDS group, the long-term mortality was mediated by the lack of immune recovery at 2 years. Finally, LD compared with non-LD and, particularly, among the former, LD-AIDS over LD asymptomatic showed a greater risk of treatment failure.
In recent years, LD subjects, particularly, AIDS presenters, remained at a higher risk of poorer outcomes. Public health strategies for early HIV diagnosis are urgently needed to constrain the mortality gap.
关于近年来晚期HIV诊断（LD）的长期结局的数据有限。
纳入2009年至2022年在ICONA队列中登记的所有HIV感染者，这些感染者在诊断后4个月内开始抗逆转录病毒治疗（ART），并分为：（i）ART前CD4细胞计数≥350/mm³且无艾滋病（非LD），（ii）ART前CD4细胞计数<350/mm³且无艾滋病（LD无症状），以及（iii）ART前有艾滋病事件（LD - 艾滋病）。评估了死亡率（全因和特定病因）及治疗失败的估计概率和独立风险。
在6813名参与者中（2448名非LD，3198名LD无症状，1167名LD - 艾滋病），161人（2.4%）在开始ART后死亡。在生存分析中，已确定LD组的全因死亡率概率高于非LD组（P<0.001），且在前者中，LD - 艾滋病组高于LD无症状组（P<0.001）。在对混杂因素进行调整后，LD显示出更高的全因死亡风险（与非LD相比，调整后风险比[aHR]为5.51，P<0.001），特别是，出现艾滋病症状预示着更高的全因死亡风险（aHR = 4.42，P<0.001）、艾滋病相关死亡风险（调整后亚风险比[aSHR] = 16.86，P<0.001）和非艾滋病相关死亡风险（aSHR = 1.74，P = 0.022），高于其他晚期就诊者。在LD - 艾滋病组的短期幸存者中，长期死亡率是由2年时免疫未恢复介导的。最后，与非LD相比，LD，特别是在前者中，LD - 艾滋病组高于LD无症状组，显示出更高的治疗失败风险。
近年来，LD患者，特别是出现艾滋病症状者，仍面临较差结局的更高风险。迫切需要采取公共卫生策略进行早期HIV诊断，以缩小死亡率差距。
